General Surgery

It is with a certain degree of trepidation that I present this Review of General Surgery 1989 and I suspect general surgical readers will understand why. Not only is this my first attempt at such a venture, and I have had a hard act to follow, but each year sees an exponential increase in the number of published articles and a commensurate proliferation of new surgical journals. As 'general' surgeons become more specialized and concentrate on specific organs or diseases it becomes increasingly difficult to keep abreast of all advances in each field. Nevertheless, in this review I have attempted to highlight in as critical a manner as possible some of the important developments which general surgeons might find of value. I am sure this selection will not be everyone's choice and I apologise in advance for any glaring omissions or inappropriate inclusions. I have not included either endocrine surgery or vascular surgery in the review but have concentrated on major developments in other fields.


Introduction
It is with a certain degree of trepidation that I present this Review of General Surgery 1989 and I suspect general surgical readers will understand why. Not only is this my first attempt at such a venture, and I have had a hard act to follow, but each year sees an exponential increase in the number of published articles and a commensurate proliferation of new surgical journals. As 'general' surgeons become more specialized and concentrate on specific organs or diseases it becomes increasingly difficult to keep abreast ofall advances in each field. Nevertheless, in this review I have attempted to highlight in as critical a manner as possible some of the important developments which general surgeons might find of value. I am sure this selection will not be everyone's choice and I apologise in advance for any glaring omissions or inappropriate inclusions.
I have not included either endocrine surgery or vascular surgery in the review but have concentrated on major developments in other fields.

Emergency surgery
Whatever the particular interests of a general surgeon, one common feature is the practice of 'emergency surgery'. Indeed, a reasonable definition of a 'general surgeon' might be a surgeon whose name appears on the hospitals surgical emergency rota! Acute appendicitis Can there be anything new to say about this, the commonest of all disorders which has been confronting surgeons for over 100 years? Sadly, accurate diagnosis still remains a problem. Although it is stated that senior surgeons can make an accurate diagnosis in over 80% of cases, junior surgeons may be wrong in up to 50% of patients.
Hoffman and Rasmussen' have reviewed the available diagnostic aids which may assist in reducing the 15-30% negative laparotomy rate. Useful studies are ultrasonography, laparoscopy and computer aided diagnosis. Ultrasound which recognizes echodensity of the lumen, mucosa and thickened appendix wall has a sensitivity between 75-89% and a specificity of 86-100%.2 Laparoscopy can be difficult and is contraindicated in many patients. Nevertheless, it has reduced the negative laparotomy rate by as much as 50% in some series. Unfortunately complications have been reported and clearly significant expertise, as well as specialized equipment, are required.
Much interest has also been generated in computer-assisted diagnosis. Enthusiasm, however, has been tempered by the need for sophisticated equipment and personnel. In many studies, however, the negative laparotomy rates have dropped to 5-10% and more importantly the incidence of appendiceal perforation down from 20% to 5%. It has often been stated that computers stimulate the clinician to function more accurately and efficiently in gathering clinical data. There is no substitute for a careful history and examination! One major problem in diagnosis is the frequency with which gastrointestinal infections can mimic appendicitis. This is particularly so for Yersinia enterocolitica which can result in acute terminal ileitis. Moreover, the relationship between Yersinia and acute appendicitis is deserving of more study. It has been suggested that suppurative appendicitis is a secondary infection of an appendix that is primarily infected with Yersinia and that patients with non-specific right iliac fossa pain may have Yersinia infection in the lymphoid tissue of the appendix, terminal ilium or mesenteric nodes.3 In difficult patients this diagnosis should be considered and is made on the basis of culture of the organism and a demonstration of a rise of specific antibodies.
A further interesting problem in appendicitis relates to infective complications. Antibiotic prophylaxis has undoubtedly reduced wound infection 1. TAYLOR rates but the optimum combination is still controversial. Pollock et al. 4 have reported the use of subcutaneous infiltration ofamoxycillin/clavulanic acid. Wound infection rates were significantly lower in this group and no significant differences were found in the incidence of other infective complications when compared to intravenous injection.
Gastrointestinal haemorrhage Even in 1990 major gastrointestinal haemorrhage is a significant source of morbidity and mortality.
Following resuscitation an accurate and rapid diagnosis of the site of bleeding is essential so that effective treatment can be instituted. Rossini et al. 5 have reviewed their extensive experience of emergency colonoscopy in patients with active lower gastrointestinal bleeding. They were able to identify the site of bleeding in 80% of cases with a very low complication rate and treat the source of haemorrhage either by polypectomy (in 18 patients) or electrocoagulation (1 patient with angioma, 9 patients with angiodysplasia). They make a strong case, which many would agree with, for emergency colonoscopy being the first choice examination in any patient with massive lower gastrointestinal bleeding. Trudel et al. 6 described very similar results in their series in which diagnosis was established in 50% of patients and in 28 patients treated by endoscopic coagulation, 68% were controlled.
Another technique worthy of consideration in the difficult case is technetium-99m red blood cell scintigraphy. Nicholson et al. 7 have described its use in 41 patients with major rectal bleeding. The red cells are labelled in vivo and serial scans taken with a large field gamma camera. A definite bleeding site was identified in 30 cases and red cell scintigraphy correctly localized 29 of these (sensitivity 97%). In the remaining 13 cases a bleeding site was not identified and there were 2 false positive scans (specificity 85%). Scintigraphy can detect bleeding rates of 0.05-0.1 ml/min and is particularly valuable for lesions which bleed either slowly or intermittently, e.g. colonic angiodysplasia. We have utilized this technique on 3 occasions in Southampton in recent months and in each patient a definite bleeding site was recognized enabling localized colonic resection to be satisfactorily performed.
Such techniques should reduce the need for 'blind' right hemicolectomy in colonic bleeding as recently advocated by Milewski and Schofield.8 Nevertheless, in their series of 14 patients right hemicolectomy including the right half of the transverse colon resulted in a satisfactory outcome, although one patient re-bled at 11 months.
The prognosis associated with massive upper gastrointestinal haemorrhage from peptic ulceration is still poor with mortality rates of over 20%. An attempt has been made to recognize the 'high risk' patient so that effective stratification ofappropriate treatment can be made. Schein and Gecelter9 have utilized the APACHE II scoring system in 96 patients undergoing surgery for gastric ulcers and 58 for duodenal ulcers. None ofthe 66 patients with an APACHE II score <11 died while the mortality rate in those who scored > 10 was 22%. They suggest that such a scheme might recognize highrisk patients in whom a procedure of lesser magnitude is more likely to improve survival. One cannot help but feel that such a scheme is unlikely to prove popular. Most surgeons are likely to rely more on their own experience and expertise rather than being confined by a prognostic score.

Acute pancreatitis
Acute pancreatitis remains a major clinical problem even now, associated with significant morbidity and mortality. Two dilemmas face the clinician. Firstly, is it possible to recognize, at an early stage, the patients with severe pancreatitis who might require surgical intervention? Secondly what is the most effective surgical management?
The value of contrast enhanced abdominal computed tomographic scanning (CT) used prospectively in acute pancreatitis has been described in 2 very similar papers by London et al.1'1' Highly significant differences were noted in pancreatic enhancement, peripancreatic tissue planes and indeed in pancreatic size between clinically severe and mild cases but these criteria did not add anything to standard prognostic indices (e.g. Glasgow criteria) for prediction of disease severity. For example, the modified Glasgow criteria had a sensitivity of 85% and a specificity of 79% for clinically severe attacks compared to a 71 % and 77% respectively with a pancreatic size index on CT of > 10 cm. The aetiology of the pancreatitis was inferred from 27% of admission scans. It is surely not justified to encourage serial CT scanning on all patients with acute pancreatitis. In selected casesparticularly if pancreatic necrosis or pseudocyst is suspected, and ultrasound is unhelpfulthen CT scanning may be a valuable asset to management.
A number of biochemical tests have been investigated for prognostic value to predict and recognize disease severity. For example, serum phospholipase A2 activity has been performed during the first 6 days of admission.'2 Elevated initial activity correlated with clinical outcome and demonstrated Wilson et al."3 have measured complement factors, antiproteases (a2-macroglobulin and a,-antiprotease), and C-reactive protein to determine the value of sequential measurement in prediction of outcome relative to clinical prognostic scoring systems. C-reactive protein was the best discriminator between mild and complicated attacks. It is also the simplest and quickest to perform. In effect a C-reactive protein of greater than 300 mg/l and which remains persistently elevated at the end of the first week provides a useful warning of the development of local pancreatic complications. It would appear reasonable to select out such patients for contrast-enhanced computed tomography and perhaps monitor such patients in an intensive care unit.
Finally, the APACHE-2 score has been assessed in acute pancreatitis. Larvin and McMahon'4 demonstrated in 290 attacks of acute pancreatitis that outcome can be correctly predicted in 77% of attacks and identified 63% as severe compared to 44% achieved by clinical assessment. APACHE-2 was most accurate after 48 hours when it correctly predicted outcome in 88% of attacks. Once again this score may be used to select rapidly groups of patients for further investigation or intensive therapy and may indicate the development of a pancreatic mass.
There are now a large number of clinical and biochemical investigations which can be used to accurately predict at a fairly early stage those patients with acute pancreatitis who are likely to develop a severe and complicated course. Such tests are widely available and should be utilized to provide appropriate intensive care in the hope that high mortality rates can be reduced.
The timing of surgical intervention in severe pancreatitis and deciding on the most effective procedure to perform have always been highly controversial issues. Kune and Brough'5 reviewed the results of surgical intervention in a group of476 consecutive patients with severe acute pancreatitis. The indications were: laparotomy for diagnosis (77), excision of necrotic pancreas (7) and complications (18 pseudocysts, 53 pancreatic abscesses, 17 persistent obstructive jaundice and large bowel problems). There are several suggestions put forward from this experience but the main cause of mortality was pancreatic abscess formation and haemorrhage associated with them. All pancreatic abscesses underwent laparotomy, necrosectomy, debridement of peripancreatic and retropancreatic slough and drainage of pus. Re-operation was required in 13% of patients and 19% of patients with a pancreatic abscess died.
The surgical management of pancreatic necrosis and abscess formation should be to remove all necrotic areas with adequate drainage. As mentioned, re-operation is frequently required and mortal-ity high. Larvin et al. ' for the first 2 days) and 35 randomized to control. Mortality in both groups was low but there was a tendency to fewer local complications in the somatostatin group (6 vs 2 pancreatic inflammatory swellings).
Finally, the factors influencing the development of severe gallstone pancreatitis have been the subject of intense interest. Neoptolemos'9 has examined the role of common bile duct stones. The study was based on ERCP findings in 131 patients. It is suggested that small migrating stones tend to initiate the attack whereas larger 'persisting' stones tend to convert a mild attack into a severe one. In addition a prospective randomized trial20 has indicated that ERCP performed within 72 hours of the attack results in a marked improvement in patients with predicted severe attacks and enables removal of common bile duct stones following sphincterotomy. This would tend to confirm the importance of larger persisting stones in the development of severe gallstone pancreatitis.

The biliary tract
This aspect no longer remains the exclusive province of the general surgeon. Increasing technical innovation has enabled many common problems associated with gallstone development to be treated without the need for surgical intervention. However, it is important for general surgeons to be aware of alternative methods of management and indications for each. Undoubtedly the majority of patients with gallbladder disease will continue to require surgical treatment in the foreseeable future but rapid changes are occurring.
Once biliary pain occurs the chances of further trouble are high. About one-third of patients who remain well for one year after gallstones have been diagnosed develop severe biliary colic and a fifth copyright. on 24 July 2018 by guest. Protected by http://pmj.bmj.com/ acute cholecystitis or other serious complications over the following 11 years.20 As misdiagnosis should now occur in less than 5% of patients as a result of improvements in ultrasonography and radionuclide imaging, cholecystectomy should be performed within a week of hospital admission. This policy has now been shown in several studies to result in morbidity and mortality no greater than that for elective cholecystectomy,2' even in the elderly. 22 There are, however, changing trends in surgery for benign gallbladder disease. Gutman et al. 22 has reported on 2181 consecutive cholecystectomies performed between 1969 and 1984. Over the years the population has become older, the proportion of males is increasing and there is an increasing incidence of diabetes. Periods of hospitalization have been reduced perhaps due to prophylactic antibiotics and anticoagulants.
Extracorporeal shock-wave lithotripsy may in due course alter the recommendations for cholecystectomy. Sackmann et al. 24 and Darzi et al.25 have discussed their experience and indications for this form of treatment. Generally selection is limited to patients with symptomatic gallstone disease, with radiolucent stones of any size or number or radio-opaque stones less than 3 cm and a functioning gallbladder on oral cholecystography. Patients also receive a combination dissolution treatment comprising chenodeoxycholic and ursodeoxycholic acid. There is usually a maximum of 6 treatments at intervals of 2-3 weeks. Darzi et al.25 reported a median time to clearance of stones of 7 months. The influence of subsequent oral dissolution therapy is probably critical and Sackman et al. 26 noted that stones were completely cleared in only 30% of patients 2 months after lithotripsy compared with 93% at 18 months.
A further method for dealing with gallbladder stones is percutaneous transhepatic lysis by methyltertbutyl ether (MTBE). This has been reported in 15 patients with cholesterol gallstones.26 A special catheter is introduced into the gallbladder under local anaesthesia by percutaneous transhepatic puncture. MTBE is injected into the catheter and removed repeatedly. In 13 patients the stones dissolved, in 3 stone debris remained. Side effects were minor and the authors claim this to be a successful and inexpensive method for removal of gallstones. Further larger studies are clearly indicated to confirm these findings.
Stones in the common bile duct continue to present the surgeon with major problems. Routine peroperative cholangiography has for many years been advocated in an attempt to reduce the incidence of residual common bile duct stones. However, this policy is being increasingly questioned. Gregg,27 in a review of 765 patients undergoing operative cholangiography, advocates a more selective policy based on the cost and danger of unnecessary explorations and possible stricture development. I would certainly support this and his criteria are similar to my own, i.e. minimum jaundice, a moderately dilated common bile duct and a history of pancreatitis.
As far as removal of residual or recurrent stones in the common bile duct is concerned, endoscopic sphincterotomy is now the treatment of choice although other non-operative techniques are described. Hansell et al. 28 have reported the use of endoscopic sphincterotomy in 121 patients (median age 80 years) with intact gallbladders and bile duct stones. Clearance of the duct by basket or balloon extraction was achieved in 93 patients. In 24 the duct was left to empty spontaneously and this occurred in 22. Immediate complications due to sphincterotomy occurred in 5 patients (haemorrhage and perforation). Eighteen patients required cholecystectomy for recurrent gallbladder symptoms 1-24 months after sphincterotomy. A further 7 had recurrent colic or cholangitis necessitating repeat sphincterotomy. It is apparent that endoscopic sphincterotomy is an effective treatment for common bile duct stones in high risk patients. However, cholecystectomy is required in 18% after a minimum follow up of 1 year. Undoubtedly, more patients will require surgery as the study progresses.
Other interesting techniques for clearing stones from the common bile duct have been described. Martin et al. 29 have used pernasal catheter perfusion in patients with failed extraction after endoscopic sphincterotomy. Such a technique was successful in 73 of 74 patients. Of 55 patients in whom perfusion was continued for up to 11 days, 18 had their ducts cleared of stones. In 37 patients the bile ducts were not cleared of stones. It should be noted that 40 patients required subsequent ERCP and 12 underwent surgical removal to clear the common bile duct.
Peroral electrohydraulic lithotripsy has been described using an extra large duodenoscope and a choledochoscope to remove very large stones from the common bile duct.30 Complete clearance of 9 stones (2.2 -3.6 cm) was achieved in 5 patients with this intriguing technique.
Ascending cholangitis is associated with significant morbidity. Treatment has altered in recent years but endoscopic drainage of the biliary system is a satisfactory approach. Leung et al." have described results in 105 patients with acute calculous cholangitis who underwent urgent endoscopic drainage. Treatment was satisfactory in 102 (97%). Three of the patients in whom drainage was not successful underwent emergency surgery with 1 death. Despite successful endoscopic drainage 3 patients died of uncontrolled sepsis. It has been estimated that approximately 50% of patients with copyright. Recently the suitability of ureido penicillins, such as mezlocillin have been emphasized.32 In a randomized prospective study33 mezlocillin cured 83% of patients compared to 41% given gentamicin and ampicillin. There is a strong case for selecting mezlocillin or piperacillin in acute cholangitis.
Prophylactic antibiotics are still regarded as somewhat controversial by many surgeons. A study by Wells et al.34 has demonstrated that a selective policy of prophylactic antibiotics solely to high-risk patients cannot be justified. Many studies have confirmed that prophylactic antibiotics should be given peri-operatively to all patients undergoing gallbladder surgery.
The relationship between previous cholecystectomy and the development ofcolorectal cancer has been the subject of hot debate over the last year. The subject has been reviewed in detail by Moorehead and McKelvey" and remains controversial.
Most studies are retrospective and the selection of suitable controls is a major problem. Only large prospective studies with follow up of cholecystectomy patients by colonoscopy or barium enema will answer the question. In one such study, Moorehead et al.36 have followed 100 asymptomatic patients who had a cholecystectomy 10 years previously and underwent double contrast barium enema and sigmoidoscopy. Twelve per cent ofthese patients had colorectal tumours (8 adenomas and 4 carcinomas). In the 'control' group 3 patients had adenoma (P = 0.02). This is a small study and once again the controls are a problem. Nevertheless, larger studies are justified to determine whether patients following cholecystectomy should be regarded at 'high risk' of developing colorectal cancer. Castleden et al.37 have thrown some doubt on the hypothesis by showing that raised biliary deoxycholate concentrations are not present in patients with colon cancer and are therefore unlikely to be a major predisposing factor in the aetiology of the disease.
There are two other interesting topics which deserve mention. Ede et al.38 report a useful technique in patients with inoperable cholangiocarcinoma. Fourteen patients were treated by the insertion of iridium-192 into a previously inserted endoscopic prosthesis and 9 have survived for a median period of 16.4 months.
The diagnosis of bile duct carcinoma can be extremely difficult. Okuda et al. 39 have compared and reviewed the available ongoing techniques in a series of 37 patients. Ultrasound and CT scan were most valuable. Percutaneous transhepatic cholangiography is more valuable than ERCP if the lesion is in the hilum or above. Magnetic resonance imaging is similar to CT but its value in the diagnosis of bile duct cancer was rather limited.
Finally, the management of patients with traumatic injury to the extrahepatic tract has been reviewed by Bade et al.'" In essence gallbladder stab wounds should be repaired if possible. Partial ductal transections can be managed by primary repair but complete transections should be dealt with by primary duct jejunal anastomosis. These recommendations are made on the basis of extensive experience of stab wounds in Durban.

Upper gastrointestinal surgery
Gastro-oesophageal reflux The factors responsible for gastro-oesophageal reflux are varied. Using 24 hour ambulatory oesophageal pH monitoring in 220 patients. Johnsson et al.41 demonstrated that the pressure in the distal oesophageal high pressure zone was the single variable that correlated most strongly with the amount of reflux. The study also emphasized the role of the intra-abdominal length of the distal oesophageal high pressure zone as the primary anti-reflux barrier.
The treatment of reflux oesophagitis is initially medical. A recent trial has compared omeprazole with ranitidine in 162 patients with endoscopically proven reflux oesophagitis stratified for severity. Relief of the major symptoms of heartburn, regurgitation and dysphagia with improvement in histological appearance of mucosa was more pronounced with omeprazole. No major side effects were noted.
When surgical intervention is required there are several procedures which can be considered. Deakin  Recently controversy has developed regarding the most effective management of achalasia. Csendes et al. 47 have reported the results of a randomized prospective trial comparing forceful pneumatic dilatation with the Mosher bag with surgical anterior oesophagomyotomy in 81 patients. When late results were analysed 95% of surgical patients had excellent results compared to 65% in the ballon dilatation group with 30% failures. Surgical treatment appears more effective in the long-term.

Oesophageal cancer
Surgical resection offers the only hope of cure in patients with oesophageal cancer but few patients present with so-called 'curable' lesions. Technical problems occur frequently following resection. Two studies from Hong Kong have attempted to analyse the causes of leakage.4849 In these studies the anastomotic leakage rate is low and related to ischaemia of the oesophageal substitute. The probability of leakage was lowest when resection was performed and jejunum used as substitute. However, they still regard gastric reconstruction as the procedure of choice.
New anastomotic techniques are always of interest and two publications have demonstrated very well the use of stapling instruments for oesophageal anastomosis. Walther et al.

Gastro-duodenal surgery
There is confusion over the role of elective surgery in the treatment of chronic duodenal ulcer. Highly effective drug treatment is now available and appears to be improving all the time. In a recent double-blind trial, for example, 75% of 'resistant' duodenal ulcers were healed by prolonging antisecretory therapy with either omeprazole or ranitidine at standard dosage for 4 weeks. 52 Hansell et al. 53 have provided similar data on 55 patients selected as candidates for elective duodenal ulcer surgery who were instead entered into a maintenance cimetidine study. Sixty four per cent of patients avoided operation over a 10-year period. However, it should be noted that none had a drug-free remission. Although 90% of ulcers will heal on a 2 month course of H2-receptor antagonists, most will recur within 1 year of stopping therapy and even on maintenance therapy the relapse rate is 2.5% per month or 30% per year. In addition the number of deaths from peptic ulcer has increased and is most marked in patients over the age of 65. In England and Wales, bleeding and perforation account for 4,500 deaths annually.
Taylor54 recommends ulcer surgery for those who frequently relapse on maintenance therapy, relapse early after 3 or more 2-month courses of these drugs and those who have relapsed after 3 or more courses of the drug at or about the age of 50. He suggests that such a conservative surgical strategy could save vast amounts of money and perhaps reduce the mortality from complications.
Certainly elective ulcer surgery is safe with a mortality of 0.15-0.3%. Recently, anterior lesser curvature seromyotomy has been advocated as a simple and effective procedure. In  The curative resection rate remains at 21 % and operative mortality rates for partial and total gastrectomy are 13% and 29% respectively. There was a significant increase in survival time for those treated by curative resection between 1972 to 1981 compared to the previous decade. Overall 5 year survival was 5% at 5 years although 72% survived 5 years with Stage I disease. Clearly early diagnosis and treatment is most important. This has been emphasized by Percivale et al. 63 who, in a study of long-term follow-up of 54 patients with early gastric cancer treated by subtotal gastrectomy, report age-corrected 5-and 10-year survival rates of 95.7% and 84.3% respectively. The authors stress the need for accurate lymph node dissection.
Sadly adjuvant chemotherapy has not been demonstrated to be effective in operable gastric cancer. No survival advantage was observed with 5FU and mitomycin C in 411 patients entered into a prospective trial.' In addition, toxicity was significant. Chemotherapy also has little role in the management of advanced or recurrent gastric cancer.65 Accordingly earlier diagnosis appears the only hope for improved survival in this disease.
Finally, managing haemorrhage from inoperable gastric cancer can be difficult but Barr et al. 66 have successfully dealt with 3 such patients by means of interstitial laser photocoagulation.

Perforation ofpeptic ulcers
Several studies have demonstrated that the advent of H2-receptor antagonists has reduced the operations for elective duodenal ulcer by up to 90% but has not reduced emergency admissions.67 This is particularly noticeable with perforated duodenal ulcer. The postoperative mortality for this condition is high, particularly in patients over 70 years.' Irvin has reported a 34% mortality in this group. Particular risk factors include delayed presentation and concurrent medical illness. 69 These figures would suggest that non-operative treatment should be considered in selected patients. Berne et al. 70 have advocated, once again, such a policy providing a gastroduodenogram suggests self-sealing. Many would, however, regard this as unnecessary. In their highly selected series of 35 patients, mortality was 3% and only I patient developed an intra-abdominal abscess. Conservative treatment consists of antibiotics, nasogastric aspiration, intravenous fluids and H2-blockers.

Inflammatory bowel disease
During the year several groups have published their results of restorative proctocolectomy with ileoanal anastomosis for ulcerative colitis (and familial polyposis coli). There is no doubt that this procedure is becoming increasingly popular and technical advances ensure that it is less demanding. The pouch anal anastomosis can now be completed entirely with the ingenious use of staplesboth linear and circular.7'" 3 This ensures that the median operating time in experienced hands for a J-pouch is about two and a half hours. However, this still remains a procedure which should be performed with a great deal of respect and preoperative consideration. Even in the most experienced hands postoperative complications can be serious.
Long-term clinical and functional results of this procedure are now becoming available. Orestand et al. 74 have published results in 100 consecutive patients treated by ileo-anal anastomosis and a Jor S-shaped reservoir. There was a re-laparotomy rate of 14% for complications (sepsis, fistula and obstruction). Stool frequency stabilized at about 5 evacuations per 24 hours at 1 year, although 40% had night evacuations. Other problems included mucous leakage, sexual disturbances (8%) and dyspareunia. Patient satisfaction was reported as high and only 3 patients preferred conversion to an ileostomy. In addition the cumulative risk of pouchitis was 30% at 2 years.
The problems of pouchitis or non-specific ileitis is clearly a serious accompaniment of restorative surgery in ulcerative colitis. There have been many suggestions as to its aetiology75 but it clearly results in a good deal of morbidity. It is most likely to be the result of an abnormal host response to the underlying pathogenesis of ulcerative colitis.
The epidemiology of inflammatory bowel di-copyright. sease is of great interest in our understanding of the aetiology of these conditions and particularly their relationship to subsequent malignancy. Two excellent review articles have addressed this latter problem.7677 The conclusions ofboth are similar. In patients with long-standing total colitis colonoscopic surveillance is necessary and the appearance of severe dysplasia is an indication for surgery. It should also be noted that as a result of asymptomatic population screening for colorectal cancer, information on the prevalence of inflammatory bowel disease is available and is about 56/105. This figure suggests that traditional studies have underestimated the true prevalence by about 30%.78 Crohn's disease is characterized by a high incidence of recurrence. This risk of recurrence and reoperation has been investigated in a careful study from Holland.79 Two hundred and ten patients were followed up after surgical resection. Life table analysis showed that after 10 years 17% required further resection for recurrence and 8% for relapse. By 20 years the rate of recurrence had risen to 56%. An intriguing study from Cardiff 80 has suggested, albeit on retrospective data, that the incidence of recurrence in Crohn's disease may be reduced in patients who received a perioperative blood transfusion. Five years after bowel resection the cumulative recurrence rate in transfused patients was 19% compared with 59% in controls.
In Crohn's disease those patients with short fibrous strictures may benefit from strictureplasty. However, the lesions are often multiple and the procedure may need to be repeated. Dehn et al.8' from Oxford and Sayfan et al. 82 from Birmingham have discussed their experiences with this technique. In selected patients it is of value and can be carried out safely. It is an alternative to wide or multiple resections and should be considered.
Other complications of Crohn's disease require surgical intervention but the timing and type of procedure may be difficult to determine. Enterovesical fistulas can occasionally be managed conservatively but Heyen et al. 83 in reporting the experience from Birmingham favour resection of symptomatic fistulas with primary anastomosis if possible. Most would agree that the bladder defect should be closed over an indwelling catheter and not be removed until there is radiological confirmation of satisfactory healing. Greenstein et al.84 in reviewing the indications for repeated surgery in Crohn's disease observed that operations for perforating indications were followed by reoperation approximately twice as quickly as operations for non-perforating indications.
Two final therapeutic points require comment in the management of Crohn's disease. In patients with painful anal Crohn's in which there is no evidence of sepsis but deep cavitating ulceration, local depot methyl prednisolone injection may be beneficial and is worth trying.85 The benefit of preoperative total parenteral nutrition in patients with severe Crohn's disease has been evaluated in 67 patients with serious complications, such as fistulas or obstruction.86 Spontaneous closure of fistulas was achieved in 75% of patients and mean body weights improved. Although expensive, such a regimen may provide significant advantage to patients with active Crohn's.

Cancer
Colorectal cancer is common throughout the Western World. Armstrong et al. 87 have indicated that it may be even more common than anticipated. In a post-mortem study over a 10-year period 61 cases of unsuspected colorectal cancer were found. The carcinoma was the primary cause of death in 57 cases. Many would have been operable if diagnosed. It is not surprising, therefore, that increasing interest surrounds the concept of screening. Hardcastle and Pye88 have reviewed critically the present position of colorectal cancer screening and indicate most of the difficulties and pit falls. Haemoccult has a positive predictive value for invasive cancer of 11-17% and for adenomas 36-41%. This specificity is achieved, however, at a loss of sensitivity, the interval cancer rate reported in screening studies being over 20%. In the Nottingham study89 of 107,346 asymptomatic individuals 2.3% of test subjects were positive and 63 cases were detected (52% Stage A) as well as 367 adenomas. Only 10.6% of cancers in the control group were Dukes A. These are promising data but it is still too early to show any effect of screening on mortality in colorectal cancer. It is unlikely that a more specific test, such as an immunological one, will be more effective since Pye et al.9 have shown that an increase in specificity is associated with a fall in sensitivity with a resulting enormous increase in laboratory work load. Other screening tests which have been evaluated include self-administration ('D.I.Y.') tests.9' However, these are most unreliable with an unacceptable specificity.
Two interesting studies could provide some insight into the aetiology of colorectal cancer. Hirayama92 on the basis of a Japanese cohort study has demonstrated a relationship between sigmoid cancer and alcohol consumption. Ghahremani et al.93 have demonstrated, in a retrospective study, that there has been a 10.2% increase in right-sided colon cancers compared to a 15.8% decrease in the same time period of rectal and rectosigmoid carcinomas. This information clearly has implications with regard to diagnostic methods in colorectal cancer.
Factors affecting prognosis and the accurate prediction of prognosis in colorectal cancer have also attracted a good deal of attention in the last copyright. year. The influence of age on survival after curative resection has been investigated by Svendsen et al. 94 In a multivariate analysis of 1623 consecutive patients, Dukes C stage, poor differentiation and age between 40-60 reached independent prognostic significance. This age group had a poorer prognosis than other groups despite the fact that younger patients had more advanced tumours. Other groups have utilized similar multivariate analyses to identify specific prognostic features. Domergue et al.95 in 208 patients with rectal cancer identified lymph node status, tumour infiltration, histological type and preoperative radiotherapy. Barillari et al.96 in 571 patients with colorectal cancer looked specifically at symptom duration and survival but did not find any relationship between the duration of intestinal symptoms and stage or prognosis of colorectal cancer.
Peri-operative blood transfusion had also been investigated to determine whether it does indeed represent an independent prognostic factor. Vente et al.97 in a study of 212 patients were unable to demonstrate such an effect but Stephenson et al. 98 found an adverse relationship between transfusion and survival of patients who had undergone resection of colorectal liver metastases. This is still a controversial topic and as yet the relationship between survival and transfusion is not proven.
Prospective studies are required to confirm the dilemma. In an animal model, however, Carty et al.99 were unable to determine a deleterious effect of syngeneic blood transfusion.
Two novel diagnostic techniques in colorectal cancer deserve mention. Rectal endosonography in rectal cancer is becoming increasingly widespread. It appears to be more accurate in staging local invasion preoperatively than either digital examination or CT scans."'°In experienced hands it has an accuracy of over 80% in predicting mesorectal lymph node involvementl'' as well as definitive evidence of local extrarectal recurrence.
Radioimmunoscintigraphy has also attracted some recent attention. Anti-CEA monoclonal antibodies are most popular for this technique and Granowska et al.'02 have reported a prospective study using "'In-labelled CEA in 23 patients with colorectal cancer. A sensitivity of 95% was found with an overall accuracy of 91 %. Well and moderately well differentiated tumours took up about 4 times more antibody than poorly differentiated tumours. This technique has yet to be of widespread value in the diagnosis of recurrent disease but the impetus is present for further studies.
The present status of tumour markers in large bowel cancer has been reviewed by Moore et al.'03 There is little doubt that with the progress in molecular analysis of colorectal cancer'0" constitutional genotypic markers are now being identified which may shortly be available as tumour specific markers and are likely to be far more useful than existing ones such as CEA and CA 19-9.
Colonoscopic examination of the colon in patients with established colorectal cancer has been investigated in a study by Tate et al.105 It would appear that early postoperative colonoscopy is likely to be most helpful in revealing small polyps. Treatment Treatment for colorectal cancer is predominantly surgical. The results of surgery alone, however, have not significantly improved the prognosis for this disease for many years. Nevertheless surgery is now much safer and postoperative morbidity and mortality are reducing. Canivet et al.'06 have reviewed mortality in 476 patients operated on between 1973-1986. Operative mortality overall was 13.4%. However, this fell from 20.1% in 1973-79 to 7.8% in 1980-86. Specific risk factors were chronic obstructive airways disease, and previous myocardial infarction although age and emergency procedures were both important. The specific problem of obstruction has been investigated by Serpell et al.'07 There is no doubt that survival in patients presenting with obstruction is significantly worse than in non-obstructed patients. In this series 5 year survival was 59.1 % compared to 31.8% (P<0.001). This is probably in part related to the higher incidence of more advanced disease with far fewer Dukes A lesions. Nevertheless it would appear that completely obstructing colonic cancers are more aggressive than others. Malignant cells 'spilled' at surgery or in close proximity to a healing anastomosis or laparotomy scar have enhanced growth potential.'08 This observation, confirmed in an animal model, has implications in emphasizing the need for surgeons to wash out the lumen of the bowel and the tumour bed, after surgical excision, with cytotoxic agents.
The question of adjuvant therapy of colorectal cancer is still under investigation and we still do not know whether it is beneficial. As Buyse et al.'09 point out this is probably related in part to inadequate trials and insufficient patient numbers. Trials much larger than those published are required if adjuvant chemoor radiotherapy are to be confirmed as being significantly beneficial. A metaanalysis of radiotherapy trials indicate that the incidence of local recurrence is reduced but this is not translated into unequivocal survival benefit. An example of this is the recent EORTC study"0 of 466 patients receiving preoperative radiotherapy. Local recurrence rates at 5 years were 30% and 15% (P = 0.003) respectively for control and radiotherapy. The effect was most marked in patients with locally advanced disease. However, 5 year survival rates were 59.1 % and 69.1 % respec-copyright. on 24 July 2018 by guest. Protected by http://pmj.bmj.com/ tively (P = 0.08). Levamisole, an immune stimulator has also been assessed as an adjuvant in colorectal cancer. Arnaud et al."' have reported the use of levamisole in 297 patients with Dukes C colon cancer. The drug is well tolerated but no significant survival differences, or number of relapses were found in patients receiving levamisole compared to placebo.
For rectal cancer adjuvant multimodality therapy may be beneficial, combining attempts to control local recurrence with prevention of disseminated disease. Patient selection should be refined and enhanced therapeutic effect associated with minimal toxicity.
This year has seen an explosion of interest in the use of laser therapy in the management of colorectal cancer. In patients with advanced local disease who require palliation but are inoperable Nd-YAG laser treatment has a role. Several studies have indicated a benefit"2-'14 even for benign polypoid lesions. Laser combined with photodynamic therapy may enhance the response and has been suggested in addition for small tumours in the colon and rectum, anastomotic recurrences as well as dysplastic field changes."5 One study, however, has suggested that although initial palliation can be achieved in over 80% of patients this is maintained in only 51% and 41% of patients surviving 6 months and 12 months respectively." 6 More traditional methods of treating recurrent and advanced disease involve combinations of surgery (if possible), radiotherapy and chemotherapy. Pollard et al."7 question whether surgery is worthwhile for recurrent colorectal cancer. In a series of45 patients undergoing a second operation those having a potentially curative resection had a survival of 71 % at 2 years compared to a median survival of 10 months when a palliative procedure was performed. In obstructed patients, as expected, palliative resection was better than bypass but it is difficult to predict patients who do well. As far as radiotherapy is concerned Griffiths et al."8 have confirmed its role in the palliation of severe local symptoms with useful improvement in symptoms in 80%.
The management of patients with established liver metastases continues to attract a good deal of interest. Resection of solitary lesions (or certainly less than 4) in one lobe can be carried out with a low morbidity and mortality and offers a realistic therapeutic option with 50-60% 2 year survivals."9 However, such patients represent only approximately 5% of all patients with multiple colorectal liver metastases. New loco-regional approaches to this problem have been advocated but few are carefully assessed. Hunt et al.'20 have critically reviewed the role of chemotherapy for both prophylaxis and treatment ofliver metastases. In selected patients with less than 50% involve-ment, hepatic arterial chemotherapy with starch degradable microspheres may have a role. Such treatment has been advocated using either 5FU or mitomycin and promising results have emerged.'2' Nevertheless, further clinical trials to assess the optimal sequence and dosages are required. It is increasingly important to select specific treatments for individual patients and this should be based on, amongst other parameters, the percentage hepatic replacement with tumour. Two studies have attempted to accurately calculate this using either liver blood flow scanning'22 or liver imaging.123 Finally, anal carcinoma appears to be increasing in incidence and the management of this condition at St Marks Hospital between 1948-1984 has been reviewed.'24 Prognosis depends on depth of invasion and the benefit of radiotherapy, particularly for locally invasive disease, is becoming increasingly established. As far as Bowen's disease of the anus is concerned, local excision, often without skin grafting, is a reasonable approach ifassociated with a policy of careful follow-up.'25

Miscellaneous
The management of colorectal trauma is extremely difficult and continues to challenge surgeons. Trauma is either penetrating or blunt and always associated with severe peritoneal contamination and septic complications.
Two studies from the USA claim good results from contradictory policies. Therapeutic colonscopy is widening its horizons quite significantly. Novel uses include the balloon dilatation of colonic anastomotic strictures,'28 colonoscopic decompression in pseudo-obstruction,12 and Nd-YAG laser photocoagulation for bleeding intestinal vascular abnormalities.'30 Satisfactory results have been claimed for each of these innovations and surgeons should be aware of these therapeutic options in difficult selected patients.
Finally, major abdominal surgery (including colonic surgery) in the over-eighties has been assessed in a prospective clinical trial.'3' There is no doubt this is associated with an increased mortality and increased post-operative dependency compared to similar surgery in 40-80 year olds. This factor must be taken into account when deciding on treatment options in the elderly. Benign breast disease comprises over 90% of the breast pathology seen by surgeons. One of the commonest complaints is mastalgiaboth cyclical and non-cyclical. Maddox et al.'32 have suggested a classification and treatment protocol for the latter. Persistent symptoms respond to drug therapy (danazol especially); musculoskeletal pain was relieved in over 90% of patients with injections of steroid and local anaesthetic.
Wilkinson et al.'33 have reviewed the outcome in 110 women under 35 with fibroadenomas. Cytology is absolutely essential to exclude malignancy if a conservative policy is followed. A period of greater than 12 months may be required for resolution and as such a simpler policy is removal of the lump as a day case.

Breast cancer
With the introduction of a National Breast Screening Programme in the UK during 1989 there has been a significant proliferation of articles related to this aspect. Controversy still exists regarding the benefit of breast screening and recent views have been expressed from the experience in the USA,'34 Sweden'35 and the UK.'36 All these studies tend to suggest a benefit in reducing breast cancer mortality by up to 30%. However, other views would lend less support to the cost/benefit analysis. In addition to mammographic screening, breast self-examination has also been evaluated'37 but no overall survival advantage observed. Nevertheless, it should be regarded as an adjunct to mammographic screening in post-menopausal women. Two other factors are of importance in the organization of mammographic screening. Firstly, compliance; McEwan et al. '38 have highlighted the importance of awareness, information and accuracy of the GPs data base; Williams and Vessey'39 have demonstrated the benefit of including an appointment in the invitation for screening rather than an open-ended invitation. Secondly, accurate evaluation of the screening programme is essential. Day et al.'40 have emphasized this aspect and the importance of carefully recording tumour characteristics and the incidence of interval cancer.
Surgeons should be involved in all aspects of screening assessment and particularly treatment. Localization biopsy of screen-detected impalpable lesions is a difficult technical exercise but is most important if in situ lesions are to be adequately excised. Techniques for performing this have been described'4' and the role of stereotactic fine needle biopsy in making accurate diagnoses has been assessed and shown to be effective. 142 Frisell et al. '43 have demonstrated from the Swedish experience that fine needle aspiration biopsy can reduce the rate of negative surgical biopsies by 90% in patients with uncertain mammograms without considerably impairing the reliability of the results.
The management of ductal carcinoma in situ (DCIS) is still extremely controversial. Whether wide excision is sufficient for localizing DCIS is not entirely clear from the review of the literature and clinical trials assessing radiotherapy are required.'" Sector mastectomy or total mastectomy for multifocal DCIS is still the treatment of choice but again randomized trials are important in this regard. The management of residual tumour after biopsy can be a major problem'45 and it is not certain that radiotherapy is an adequate treatment. Such patients frequently require either wider excision or mastectomy.
New diagnostic modalities to assist in the management of breast disease have been reported. These include radioimmunoimaging to detect bone metastases'46 and ultrasound imaging of the axilla to recognize lymph node involvement in patients with breast cancer. "' Neither of these techniques has proved totally reliable.
The primary treatment of breast cancer has always been uncertain. Conservative surgery can be safely offered to a high proportion of patients with localized breast cancer. This should be combined with breast irradiation to reduce the incidence of local recurrence. Reed and Morrison'48 advocate wide local excision alone in the elderly with no significant effects of recurrence on survival because of the relatively high mortality rate from unrelated conditions. Others would suggest tamoxifen alone in this group or tamoxifen combined with local therapy.'49 Radiotherapy following surgery can be associated with problems which should be considered in patient management. Aitken et al. ' In an attempt to improve survival the role of prophylactic endoscopic sclerotherapy has been addressed by several groups. Most recently Potzi et al.'" in a series of 87 patients demonstrated a tendency towards longer survival in patients with prophylactic sclerotherapy, particularly in those with alcoholic cirrhosis. Another non-surgical treatment worthy of comment is the use of oral propranolol. Kiire'69 in a study of 50 patients with non-cirrhotic portal fibrosis showed a statistically significant reduction in gastrointestinal haemorrhage in patients receiving propranolol for 1 year.
In those patients who continue to bleed despite intensive medical treatment surgical intervention is indicated. Oesophageal transection and devascularization is a popular procedure. Kraida et al. '70 have described the technique of oesophageal transection with gastro-oesophageal devascularization and splenectomy in 50 consecutive patients. In this group of patients with mainly schistosomiasis and hepatitis B infection a low operative mortality occurred and no recurrence ofbleeding was recorded in patients surviving for follow-up periods of 2-3 years.
In patients with either extra-hepatic portal hypertension or the Budd-Chiari syndrome the traditional surgical procedures of shunting are of little value. Szczepanik and Rudowski'7' have suggested that the former condition is best treated by repeated long term sclerotherapy and Stringer et al. '72 have described a technique of mesoatrial shunt (in 5 patients) for the latter condition.
The indications for transplantation in alcoholic liver disease have been reviewed by Neuberger.'"7 He concludes that it is reasonable to consider for transplantation patients with alcoholic hepatitis with no serious disease of other organs and no history of alcohol dependence.
Finally the management of bleeding varices in the elderly can be a particularly difficult condition to deal with. Hosking et al. '74 have compared the outcome of bleeding varices in patients aged under 65 with those over 65. Treatment was by active sclerotherapy and mortality due to the first bleed was dependent on severity of liver disease and was unrelated to age. Survival was 65% at one year and 60% at two years for both groups of patients. Accordingly, patients should not be denied active treatment for bleeding varices on the basis of age alone.

Conclusions
I mentioned at the beginning of this review that the chosen topics are unlikely to be to everyone's liking. I have attempted to cover major aspects of 'general' surgery which might influence our management of patients in the not-too-distant future. In putting together this review it has become clear to me that one really should try to keep abreast of the literature in order to ensure reasonable familiarity with the rapidly changing 'general' surgical scene so that patients can benefit from the most effective management regimens.